Emotional Support Animal 
                                      Assessment/Letter Checklist 
         
        Client Name: ________________________________  DOB: ____________  Date Completed: ______________ 
         
               Context             #                      Item                     Yes    No          Comments 
               Disability       1        The client has a disability as                         
            Determination                evidenced by… 
                                1(a)     Meets diagnostic criteria for one or                   
                                         more mental disorders based on the 
                                         most current edition of the Diagnostic 
                                         and Statistical Manual of Mental 
                                         Disorders (DSM) 
                                1(b)     Multiple data sets support the                         
                                         diagnosis, including: 
                                1(b)(1)  Structured and/or clinical                             
                                         interview(s): 
                                          
                                1(b)(2)  One or more psychological tests with                   
                                         scales designed to aid in detection of 
                                         malingering or exaggeration of 
                                         symptoms 
                                1(b)(3)  One or more collateral sources (e.g.,                  
                                         records, interview(s) with 
                                         family/significant others): 
                                          
                                1(c)     One or more functional impairments                     
                                         have been identified, such as: 
                                1(c)(1)  Limited ability to concentrate or focus                
                                         on activities/tasks 
                                1(c)(2)  Limited expressive and/or receptive                    
                                         communication 
                                1(c)(3)  Difficulty relating appropriately with                 
                                         others 
                                1(c)(4)  Responds inappropriately to social                     
                                         situations 
                                1(c)(5)  Limitations in organization and                        
                                         planning 
                                1(c)(6)  Limited or no stamina to perform                       
                                         activities 
                                1(c)(7)  Limited stress, frustration, or anger                  
                                         tolerance 
                                1(c)(8)  Other: _________________________                       
                                         _______________________________ 
                                         _______________________________ 
               Context             #                      Item                     Yes    No          Comments 
                                2        These impairments (listed in #1                        
                                         above) impact one or more major life 
                                         activities, such as: 
                                2(a)     Caring for one’s self                                  
                                2(b)     Performing manual tasks                                
                                2(c)     Walking                                                
                                2(d)     Hearing                                                
                                2(e)     Speaking                                               
                                2(f)     Breathing                                              
                                2(g)     Learning                                               
                                2(h)     Working                                                
                                2(i)     Other: _________________________                       
                                         _______________________________ 
                                         _______________________________ 
                                3        The client has an animal that…                         
                                3(a)     …is individually trained or able to                    
                                         provide assistance to the client, or 
                                3(b)     …is shown by documentation to be                       
                                         necessary for the emotional well-
                                         being of a client 
            Air Carrier and     3(c)     …is trained to behave appropriately in                 
          Access Act/14 CFR,             a public setting 
               Part 382         4        The client needs the emotional                         
                                         support animal for air travel and/or 
                                         activity at the passenger’s 
                                         destination 
                                5        The client’s emotional support                         
                                         animal is not a pet.  It works, 
           Fair Housing Act              provides assistance, performs tasks 
                                         for the client, or provides emotional 
                                         support that alleviates one or more 
                                         identified symptoms 
                                6        Potential risks and benefits                           
                                         associated with the use of ESAs 
          Appropriateness/               (clinical and ethical/legal) have been 
           Efficacy of ESA,              explored with the client, and the 
          Informed Consent               client is making an informed choice 
                                         to include the ESA in his/her 
                                         treatment plan 
                                7        The therapist mutually agrees to the                   
                                         course of treatment on therapeutic 
                                         grounds 
                                8        Appropriate release forms have been                    
                                         signed by the client and a witness 
                                         allowing an ESA letter to be provided 
                                         to specific entities 
        Revised 3/1/18          ·          Developed by Aaron Norton, LMHC, LMFT, CRC, CFMHE, CFBA          ·          www.nbfe.net   
               Context             #                      Item                     Yes    No          Comments 
                Letter          9        The letter is provided on the mental                   
            Requirements                 health professional’s letterhead 
                                10       The letter is dated                                    
                                11       The letter is addressed to specific                    
                                         entities if possible 
                                12       The letter attests that…                               
                                12(a)    …the client has a mental or emotional                  
                                         disability recognized by the DSM 
                                12(b)    (if recommending ESA for air travel)                   
                                         …the client needs the ESA as an 
                                         accommodation for air travel and/or 
                                         for activity at the client’s destination  
                                12(c)    (if recommending ESA for housing)                      
                                         …the ESA is not a pet and…  
                                12(c)(   …works, provides assistance, or                        
                                1)       performs tasks for the benefit of a 
                                         person with a disability, and/or… 
                                12(c)    …provides emotional support that                       
                                (2)      alleviates one or more identified 
                                         symptoms or effects of a person's 
                                         disability 
                                12(d)    ...the evaluator is a licensed mental                  
                                         health professional, and the client is 
                                         under the evaluator’s professional 
                                         care 
                                13       The letter identifies the specific                     
                                         animal that serves the role of ESA 
                                14       The letter contains a disclaimer                       
                                         asserting that any evaluation of 
                                         appropriateness of the ESA’s 
                                         behavior is beyond the scope of 
                                         practice of the evaluator 
                                15       The letter is signed by the evaluator                  
                                16       An expiration date is provided for                     
                                         the accommodation(s) 
                                17       The name, credentials (spelled out                     
                                         and not just abbreviated), license 
                                         number(s), and state/jurisdiction of 
                                         license(s) are included in the letter 
         
         
                                                                                                                          
         
                                                                                                                          
         
                                                                                                                          
        Revised 3/1/18          ·          Developed by Aaron Norton, LMHC, LMFT, CRC, CFMHE, CFBA          ·          www.nbfe.net